Respiratory Assessment: How to Assess a Breathing Patient Properly

Lachlan Baillie, Registered Paramedic

10 minutes ago

7 min read

Shortness of breath is one of the most common reasons people call an ambulance or present to an emergency department, and it covers everything from mild anxiety to a patient minutes away from respiratory arrest. A good respiratory assessment helps you tell those apart quickly. It is also one of the most heavily tested skills in OSCEs and placement assessments. This guide takes you through a complete, structured respiratory assessment, from the doorway to the stethoscope, and explains what each finding actually means.

Start from the doorway

Your assessment begins before you reach the patient. In the first few seconds, you can learn a huge amount just by looking:

Position: patients in respiratory distress often sit upright or lean forward with their hands on their knees, known as the tripod position. A patient who insists on sitting up is telling you something. Never force them to lie flat.
Speech: can they speak in full sentences, short phrases, or only single words? Speech is one of the quickest and most reliable markers of severity.
Colour: pallor, a grey tinge or central cyanosis around the lips and tongue are worrying signs. Cyanosis is a late finding.
Behaviour: anxiety and agitation can be signs of hypoxia. Drowsiness in a breathless patient is a red flag that they may be tiring or retaining carbon dioxide.
Noise: you may hear wheeze, stridor or gurgling before you even reach for your stethoscope.

A breathless patient who suddenly becomes quiet and drowsy is not getting better. They may be getting tired.

Look

Respiratory rate

Count the rate properly, for at least 30 seconds. A normal adult rate is about 12 to 20 breaths per minute. A rate above 20 suggests the patient is unwell, and above 24 suggests significant illness. Research has shown respiratory rate is one of the strongest predictors of serious deterioration, and it is also the vital sign most often estimated rather than counted.

Depth and rhythm

Is the breathing deep or shallow? Regular or irregular? Some breathing patterns point towards specific causes:

Kussmaul breathing: deep, rapid, sighing breaths, seen in metabolic acidosis such as diabetic ketoacidosis. The body is trying to blow off carbon dioxide.
Cheyne Stokes breathing: cycles of gradually deeper and then shallower breaths followed by pauses, seen in severe heart failure, stroke and at the end of life.
Agonal breathing: slow, irregular gasps that are not effective breathing. Treat agonal breathing in an unresponsive patient as cardiac arrest.

Work of breathing

Look for signs that the patient is working hard to breathe:

Use of accessory muscles in the neck and shoulders.
Intercostal, subcostal or suprasternal recession, particularly in children.
Nasal flaring and abdominal breathing.
Pursed lip breathing, often used by patients with COPD to keep their airways open.
Prolonged expiration, typical of asthma and COPD.

Chest shape and movement

Expose the chest where appropriate and look for symmetry. Unequal chest rise may suggest a pneumothorax, a large effusion, lung collapse or a chest wall injury. A barrel shaped chest may point to long standing COPD. Look for scars, wounds, bruising and medical devices such as pacemakers.

Feel

Chest expansion: place your hands on either side of the lower chest with your thumbs meeting in the middle. As the patient breathes in, your thumbs should move apart equally. Reduced movement on one side points to a problem on that side.
Tenderness and crepitus: important in trauma, where rib fractures are common.
Surgical emphysema: a crackling feeling under the skin, like bubble wrap, means air has escaped into the tissues, usually from the lung or airway.
Tracheal position: a deviated trachea can occur with a tension pneumothorax or large effusion, but it is a late and unreliable sign. Do not wait for it.

Percussion

Percussion is used more in hospital and exam settings than on a noisy roadside, but it is still worth understanding. Tap over the chest and compare both sides:

Resonant: normal air filled lung.
Dull: fluid or solid tissue, such as consolidation from pneumonia or a pleural effusion.
Hyperresonant: too much air, as in a pneumothorax or severe emphysema.

Listen

Auscultation is where many students lose marks, often through poor technique rather than poor knowledge.

Technique

Listen on bare skin, not through clothing.
Ask the patient to breathe in and out through their mouth, a little deeper than normal.
Compare side to side at each level, front and back, moving from the top of the chest down to the bases.
Listen to at least one full breath in each position.
Do not forget the axillae and the bases at the back, where fluid and consolidation often sit.

Normal breath sounds

Vesicular sounds are soft and low pitched and are heard over most of the lung fields. Bronchial sounds are louder and harsher and are normal over the trachea. Hearing bronchial breathing out in the lung fields can suggest consolidation.

Added sounds and what they mean

Wheeze: a continuous, musical, high pitched sound caused by air moving through narrowed small airways. Common in asthma, COPD and anaphylaxis, and sometimes in heart failure, where it is called cardiac wheeze.
Crackles: short, discontinuous popping sounds, usually on inspiration, caused by small airways snapping open. Seen in pulmonary oedema, pneumonia and pulmonary fibrosis. Fine crackles at both bases are classic for fluid overload.
Rhonchi: lower pitched, snoring or rattling sounds from secretions in the larger airways. They may change after a cough.
Stridor: a high pitched sound, usually on inspiration, caused by narrowing of the upper airway. It is louder over the neck than the chest. Causes include croup, anaphylaxis, an inhaled foreign body and airway burns. Stridor is an emergency.
Pleural rub: a creaking or grating sound from inflamed pleural surfaces, often with sharp pain on breathing.
Reduced or absent breath sounds: may indicate a pneumothorax, an effusion, lung collapse or severe bronchospasm.

The silent chest

In a severe asthma attack, wheeze can become quieter or disappear completely because so little air is moving. A silent chest in a breathless asthmatic is a sign of life threatening asthma, not improvement. Combined with exhaustion, drowsiness or a falling respiratory rate, it means the patient is close to respiratory arrest.

Measure

Oxygen saturation

The Thoracic Society of Australia and New Zealand recommends a target saturation of 92 to 96 percent for most acutely unwell adults who need oxygen, and 88 to 92 percent for patients at risk of carbon dioxide retention, such as those with COPD. Oxygen is a drug, given to correct low oxygen levels rather than to treat breathlessness alone.

Remember that a normal saturation does not mean the patient is breathing well. A patient working extremely hard can maintain a normal saturation until they suddenly tire.

End tidal carbon dioxide

Where capnography is available, end tidal carbon dioxide gives real time information about ventilation. A normal value is roughly 35 to 45 mmHg. A rising value in a drowsy patient suggests they are not breathing effectively, while the shape of the waveform can show bronchospasm. Capnography is also used to confirm the position of advanced airways.

Peak flow

In asthma, peak expiratory flow compared with the patient's best or predicted value helps grade severity, although very unwell patients may not be able to perform it, and it should never delay treatment.

The history

Once immediate threats are managed, take a focused history:

Onset: sudden breathlessness suggests a pneumothorax, pulmonary embolism, anaphylaxis or an inhaled foreign body. Gradual onset suggests infection, heart failure or a worsening chronic condition.
Associated symptoms: chest pain, fever, cough, sputum colour, haemoptysis, leg swelling, a rash or swelling of the face and lips.
Triggers: allergens, exercise, cold air, smoke or recent illness.
Past history: asthma, COPD, heart failure, previous clots, recent surgery or long travel.
Severity markers in asthma: previous intensive care admissions or intubation, recent hospital visits and frequent reliever use are all red flags for a dangerous attack.
Medications: inhalers, home oxygen, anticoagulants and recent changes.

Putting the findings together

Patterns help you form a working diagnosis:

Wheeze, prolonged expiration and a history of asthma: acute asthma.
Wheeze with a rash, facial swelling or a known allergen: think anaphylaxis.
Fine crackles at both bases, breathlessness lying flat and swollen ankles: acute pulmonary oedema from heart failure.
Fever, productive cough and focal crackles or bronchial breathing: pneumonia.
Sudden pleuritic pain and absent breath sounds on one side: pneumothorax.
Sudden breathlessness, a fast heart rate and a clear chest, especially with risk factors: consider pulmonary embolism.
Stridor: upper airway obstruction until proven otherwise.

Children

Children have smaller airways, higher respiratory rates and less reserve. Recession, nasal flaring, head bobbing and grunting are important signs of distress. Normal rates vary by age, ranging from about 25 to 60 in newborns down to about 14 to 25 in teenagers. A child who becomes quiet, floppy or bradycardic with breathing difficulty is in serious danger.

Common student mistakes

Estimating the respiratory rate rather than counting it.
Listening through clothing or only listening to the front of the chest.
Not comparing one side with the other.
Being reassured by a normal saturation in a patient working hard to breathe.
Mistaking a silent chest for improvement.
Laying a breathless patient flat.
Waiting for tracheal deviation before considering a tension pneumothorax.

Conclusion

A strong respiratory assessment follows the same pattern every time: look from the doorway, then look, feel, percuss, listen and measure, before completing a focused history. Count the respiratory rate, watch the work of breathing, compare both sides of the chest, and always interpret the saturation alongside the whole patient. Master this sequence, and you will be able to spot the patient who is tiring well before they reach the point of no return.

References

Zimmerman B, Williams D. Lung Sounds. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/NBK537253/

Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: "Swimming between the flags". Respirology. 2015;20(8):1182. https://doi.org/10.1111/resp.12620

Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Med J Aust. 2008;188(11):657. https://www.mja.com.au/journal/2008/188/11/respiratory-rate-neglected-vital-sign

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Acceptable ranges for physiological variables. https://www.rch.org.au/clinicalguide/guideline_index/Acceptable_ranges_for_physiological_variables/

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